|
Allergic Reactions
|
Facility
|
IP
|
$3,439.67
|
|
|
Service Code
|
APR-DRG 8112
|
| Hospital Charge Code |
APRDRG8112
|
| Min. Negotiated Rate |
$3,439.67 |
| Max. Negotiated Rate |
$3,439.67 |
| Rate for Payer: AHCCCS Medicaid |
$3,439.67
|
| Rate for Payer: Allwell Medicaid |
$3,439.67
|
| Rate for Payer: AZCH Complete Medicaid |
$3,439.67
|
| Rate for Payer: Banner UC Health Medicaid |
$3,439.67
|
| Rate for Payer: Mercy Care Medicaid |
$3,439.67
|
|
|
ALLERGN PNUT
|
Facility
|
OP
|
$68.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
22481457
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$61.20 |
| Rate for Payer: Aetna of AZ Commercial |
$61.20
|
| Rate for Payer: Aetna of AZ Medicare |
$19.04
|
| Rate for Payer: AHCCCS Medicaid |
$5.22
|
| Rate for Payer: Allwell Medicaid |
$5.22
|
| Rate for Payer: Allwell Medicare |
$10.20
|
| Rate for Payer: Amerigroup Medicare |
$10.20
|
| Rate for Payer: APIPA Medicare/Medicaid |
$25.40
|
| Rate for Payer: AZCH Complete Medicaid |
$5.22
|
| Rate for Payer: AZCH Complete Medicare |
$10.20
|
| Rate for Payer: Banner UC Health Medicaid |
$5.22
|
| Rate for Payer: Banner UC Health Medicare |
$10.20
|
| Rate for Payer: Bisbee Police All Plans |
$17.68
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$46.24
|
| Rate for Payer: Cash Price |
$54.40
|
| Rate for Payer: Cash Price |
$54.40
|
| Rate for Payer: Cigna of AZ Commercial |
$44.20
|
| Rate for Payer: Copperpoint Commercial |
$16.83
|
| Rate for Payer: Health Net of AZ Commercial |
$40.80
|
| Rate for Payer: Health Net of AZ Medicare |
$19.04
|
| Rate for Payer: Humana of AZ Medicare |
$10.20
|
| Rate for Payer: Mercy Care Medicaid |
$5.22
|
| Rate for Payer: Self Pay Self Pay |
$54.40
|
| Rate for Payer: TriWest Medicare |
$10.20
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$39.64
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$12.24
|
|
|
ALLERGN PNUT
|
Facility
|
IP
|
$68.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
22481457
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$17.68 |
| Max. Negotiated Rate |
$61.20 |
| Rate for Payer: Aetna of AZ Commercial |
$61.20
|
| Rate for Payer: Bisbee Police All Plans |
$17.68
|
| Rate for Payer: Cash Price |
$54.40
|
| Rate for Payer: Self Pay Self Pay |
$54.40
|
|
|
Alliance II Syringe/ Gauge Assemble
|
Facility
|
OP
|
$147.00
|
|
| Hospital Charge Code |
22926471
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$22.05 |
| Max. Negotiated Rate |
$132.30 |
| Rate for Payer: Aetna of AZ Commercial |
$132.30
|
| Rate for Payer: Aetna of AZ Medicare |
$41.16
|
| Rate for Payer: Allwell Medicare |
$22.05
|
| Rate for Payer: Amerigroup Medicare |
$22.05
|
| Rate for Payer: APIPA Medicare/Medicaid |
$54.90
|
| Rate for Payer: AZCH Complete Medicare |
$22.05
|
| Rate for Payer: Banner UC Health Medicare |
$22.05
|
| Rate for Payer: Bisbee Police All Plans |
$38.22
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$99.96
|
| Rate for Payer: Cash Price |
$117.60
|
| Rate for Payer: Cigna of AZ Commercial |
$102.90
|
| Rate for Payer: Copperpoint Commercial |
$36.38
|
| Rate for Payer: Health Net of AZ Commercial |
$88.20
|
| Rate for Payer: Health Net of AZ Medicare |
$41.16
|
| Rate for Payer: Humana of AZ Medicare |
$22.05
|
| Rate for Payer: Self Pay Self Pay |
$117.60
|
| Rate for Payer: TriWest Medicare |
$22.05
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$85.70
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$26.46
|
|
|
Alliance II Syringe/ Gauge Assemble
|
Facility
|
IP
|
$147.00
|
|
| Hospital Charge Code |
22926471
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$38.22 |
| Max. Negotiated Rate |
$132.30 |
| Rate for Payer: Aetna of AZ Commercial |
$132.30
|
| Rate for Payer: Bisbee Police All Plans |
$38.22
|
| Rate for Payer: Cash Price |
$117.60
|
| Rate for Payer: Self Pay Self Pay |
$117.60
|
|
|
ALLIANCE II SYRINGE GAUGE ASSEMBLE
|
Facility
|
OP
|
$151.70
|
|
| Hospital Charge Code |
27497399
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$22.76 |
| Max. Negotiated Rate |
$136.53 |
| Rate for Payer: Aetna of AZ Commercial |
$136.53
|
| Rate for Payer: Aetna of AZ Medicare |
$42.48
|
| Rate for Payer: Allwell Medicare |
$22.76
|
| Rate for Payer: Amerigroup Medicare |
$22.76
|
| Rate for Payer: APIPA Medicare/Medicaid |
$56.66
|
| Rate for Payer: AZCH Complete Medicare |
$22.76
|
| Rate for Payer: Banner UC Health Medicare |
$22.76
|
| Rate for Payer: Bisbee Police All Plans |
$39.44
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$103.16
|
| Rate for Payer: Cash Price |
$121.36
|
| Rate for Payer: Cigna of AZ Commercial |
$106.19
|
| Rate for Payer: Copperpoint Commercial |
$37.55
|
| Rate for Payer: Health Net of AZ Commercial |
$91.02
|
| Rate for Payer: Health Net of AZ Medicare |
$42.48
|
| Rate for Payer: Humana of AZ Medicare |
$22.76
|
| Rate for Payer: Self Pay Self Pay |
$121.36
|
| Rate for Payer: TriWest Medicare |
$22.76
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$88.44
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$27.31
|
|
|
ALLIANCE II SYRINGE GAUGE ASSEMBLE
|
Facility
|
IP
|
$151.70
|
|
| Hospital Charge Code |
27497399
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$39.44 |
| Max. Negotiated Rate |
$136.53 |
| Rate for Payer: Aetna of AZ Commercial |
$136.53
|
| Rate for Payer: Bisbee Police All Plans |
$39.44
|
| Rate for Payer: Cash Price |
$121.36
|
| Rate for Payer: Self Pay Self Pay |
$121.36
|
|
|
Allogeneic Bone Marrow Transplant
|
Facility
|
IP
|
$40,658.05
|
|
|
Service Code
|
APR-DRG 0071
|
| Hospital Charge Code |
APRDRG0074
|
| Min. Negotiated Rate |
$40,658.05 |
| Max. Negotiated Rate |
$40,658.05 |
| Rate for Payer: AHCCCS Medicaid |
$40,658.05
|
| Rate for Payer: Allwell Medicaid |
$40,658.05
|
| Rate for Payer: AZCH Complete Medicaid |
$40,658.05
|
| Rate for Payer: Banner UC Health Medicaid |
$40,658.05
|
| Rate for Payer: Mercy Care Medicaid |
$40,658.05
|
|
|
Allogeneic Bone Marrow Transplant
|
Facility
|
IP
|
$70,931.88
|
|
|
Service Code
|
APR-DRG 0073
|
| Hospital Charge Code |
APRDRG0074
|
| Min. Negotiated Rate |
$70,931.88 |
| Max. Negotiated Rate |
$70,931.88 |
| Rate for Payer: AHCCCS Medicaid |
$70,931.88
|
| Rate for Payer: Allwell Medicaid |
$70,931.88
|
| Rate for Payer: AZCH Complete Medicaid |
$70,931.88
|
| Rate for Payer: Banner UC Health Medicaid |
$70,931.88
|
| Rate for Payer: Mercy Care Medicaid |
$70,931.88
|
|
|
Allogeneic Bone Marrow Transplant
|
Facility
|
IP
|
$70,931.88
|
|
|
Service Code
|
APR-DRG 0073
|
| Hospital Charge Code |
APRDRG0071
|
| Min. Negotiated Rate |
$70,931.88 |
| Max. Negotiated Rate |
$70,931.88 |
| Rate for Payer: AHCCCS Medicaid |
$70,931.88
|
| Rate for Payer: Allwell Medicaid |
$70,931.88
|
| Rate for Payer: AZCH Complete Medicaid |
$70,931.88
|
| Rate for Payer: Banner UC Health Medicaid |
$70,931.88
|
| Rate for Payer: Mercy Care Medicaid |
$70,931.88
|
|
|
Allogeneic Bone Marrow Transplant
|
Facility
|
IP
|
$137,807.57
|
|
|
Service Code
|
APR-DRG 0074
|
| Hospital Charge Code |
APRDRG0074
|
| Min. Negotiated Rate |
$137,807.57 |
| Max. Negotiated Rate |
$137,807.57 |
| Rate for Payer: AHCCCS Medicaid |
$137,807.57
|
| Rate for Payer: Allwell Medicaid |
$137,807.57
|
| Rate for Payer: AZCH Complete Medicaid |
$137,807.57
|
| Rate for Payer: Banner UC Health Medicaid |
$137,807.57
|
| Rate for Payer: Mercy Care Medicaid |
$137,807.57
|
|
|
Allogeneic Bone Marrow Transplant
|
Facility
|
IP
|
$40,658.05
|
|
|
Service Code
|
APR-DRG 0071
|
| Hospital Charge Code |
APRDRG0071
|
| Min. Negotiated Rate |
$40,658.05 |
| Max. Negotiated Rate |
$40,658.05 |
| Rate for Payer: AHCCCS Medicaid |
$40,658.05
|
| Rate for Payer: Allwell Medicaid |
$40,658.05
|
| Rate for Payer: AZCH Complete Medicaid |
$40,658.05
|
| Rate for Payer: Banner UC Health Medicaid |
$40,658.05
|
| Rate for Payer: Mercy Care Medicaid |
$40,658.05
|
|
|
Allogeneic Bone Marrow Transplant
|
Facility
|
IP
|
$58,909.18
|
|
|
Service Code
|
APR-DRG 0072
|
| Hospital Charge Code |
APRDRG0071
|
| Min. Negotiated Rate |
$58,909.18 |
| Max. Negotiated Rate |
$58,909.18 |
| Rate for Payer: AHCCCS Medicaid |
$58,909.18
|
| Rate for Payer: Allwell Medicaid |
$58,909.18
|
| Rate for Payer: AZCH Complete Medicaid |
$58,909.18
|
| Rate for Payer: Banner UC Health Medicaid |
$58,909.18
|
| Rate for Payer: Mercy Care Medicaid |
$58,909.18
|
|
|
Allogeneic Bone Marrow Transplant
|
Facility
|
IP
|
$58,909.18
|
|
|
Service Code
|
APR-DRG 0072
|
| Hospital Charge Code |
APRDRG0073
|
| Min. Negotiated Rate |
$58,909.18 |
| Max. Negotiated Rate |
$58,909.18 |
| Rate for Payer: AHCCCS Medicaid |
$58,909.18
|
| Rate for Payer: Allwell Medicaid |
$58,909.18
|
| Rate for Payer: AZCH Complete Medicaid |
$58,909.18
|
| Rate for Payer: Banner UC Health Medicaid |
$58,909.18
|
| Rate for Payer: Mercy Care Medicaid |
$58,909.18
|
|
|
Allogeneic Bone Marrow Transplant
|
Facility
|
IP
|
$70,931.88
|
|
|
Service Code
|
APR-DRG 0073
|
| Hospital Charge Code |
APRDRG0072
|
| Min. Negotiated Rate |
$70,931.88 |
| Max. Negotiated Rate |
$70,931.88 |
| Rate for Payer: AHCCCS Medicaid |
$70,931.88
|
| Rate for Payer: Allwell Medicaid |
$70,931.88
|
| Rate for Payer: AZCH Complete Medicaid |
$70,931.88
|
| Rate for Payer: Banner UC Health Medicaid |
$70,931.88
|
| Rate for Payer: Mercy Care Medicaid |
$70,931.88
|
|
|
Allogeneic Bone Marrow Transplant
|
Facility
|
IP
|
$137,807.57
|
|
|
Service Code
|
APR-DRG 0074
|
| Hospital Charge Code |
APRDRG0073
|
| Min. Negotiated Rate |
$137,807.57 |
| Max. Negotiated Rate |
$137,807.57 |
| Rate for Payer: AHCCCS Medicaid |
$137,807.57
|
| Rate for Payer: Allwell Medicaid |
$137,807.57
|
| Rate for Payer: AZCH Complete Medicaid |
$137,807.57
|
| Rate for Payer: Banner UC Health Medicaid |
$137,807.57
|
| Rate for Payer: Mercy Care Medicaid |
$137,807.57
|
|
|
Allogeneic Bone Marrow Transplant
|
Facility
|
IP
|
$58,909.18
|
|
|
Service Code
|
APR-DRG 0072
|
| Hospital Charge Code |
APRDRG0074
|
| Min. Negotiated Rate |
$58,909.18 |
| Max. Negotiated Rate |
$58,909.18 |
| Rate for Payer: AHCCCS Medicaid |
$58,909.18
|
| Rate for Payer: Allwell Medicaid |
$58,909.18
|
| Rate for Payer: AZCH Complete Medicaid |
$58,909.18
|
| Rate for Payer: Banner UC Health Medicaid |
$58,909.18
|
| Rate for Payer: Mercy Care Medicaid |
$58,909.18
|
|
|
Allogeneic Bone Marrow Transplant
|
Facility
|
IP
|
$137,807.57
|
|
|
Service Code
|
APR-DRG 0074
|
| Hospital Charge Code |
APRDRG0071
|
| Min. Negotiated Rate |
$137,807.57 |
| Max. Negotiated Rate |
$137,807.57 |
| Rate for Payer: AHCCCS Medicaid |
$137,807.57
|
| Rate for Payer: Allwell Medicaid |
$137,807.57
|
| Rate for Payer: AZCH Complete Medicaid |
$137,807.57
|
| Rate for Payer: Banner UC Health Medicaid |
$137,807.57
|
| Rate for Payer: Mercy Care Medicaid |
$137,807.57
|
|
|
Allogeneic Bone Marrow Transplant
|
Facility
|
IP
|
$137,807.57
|
|
|
Service Code
|
APR-DRG 0074
|
| Hospital Charge Code |
APRDRG0072
|
| Min. Negotiated Rate |
$137,807.57 |
| Max. Negotiated Rate |
$137,807.57 |
| Rate for Payer: AHCCCS Medicaid |
$137,807.57
|
| Rate for Payer: Allwell Medicaid |
$137,807.57
|
| Rate for Payer: AZCH Complete Medicaid |
$137,807.57
|
| Rate for Payer: Banner UC Health Medicaid |
$137,807.57
|
| Rate for Payer: Mercy Care Medicaid |
$137,807.57
|
|
|
Allogeneic Bone Marrow Transplant
|
Facility
|
IP
|
$58,909.18
|
|
|
Service Code
|
APR-DRG 0072
|
| Hospital Charge Code |
APRDRG0072
|
| Min. Negotiated Rate |
$58,909.18 |
| Max. Negotiated Rate |
$58,909.18 |
| Rate for Payer: AHCCCS Medicaid |
$58,909.18
|
| Rate for Payer: Allwell Medicaid |
$58,909.18
|
| Rate for Payer: AZCH Complete Medicaid |
$58,909.18
|
| Rate for Payer: Banner UC Health Medicaid |
$58,909.18
|
| Rate for Payer: Mercy Care Medicaid |
$58,909.18
|
|
|
Allogeneic Bone Marrow Transplant
|
Facility
|
IP
|
$40,658.05
|
|
|
Service Code
|
APR-DRG 0071
|
| Hospital Charge Code |
APRDRG0073
|
| Min. Negotiated Rate |
$40,658.05 |
| Max. Negotiated Rate |
$40,658.05 |
| Rate for Payer: AHCCCS Medicaid |
$40,658.05
|
| Rate for Payer: Allwell Medicaid |
$40,658.05
|
| Rate for Payer: AZCH Complete Medicaid |
$40,658.05
|
| Rate for Payer: Banner UC Health Medicaid |
$40,658.05
|
| Rate for Payer: Mercy Care Medicaid |
$40,658.05
|
|
|
Allogeneic Bone Marrow Transplant
|
Facility
|
IP
|
$40,658.05
|
|
|
Service Code
|
APR-DRG 0071
|
| Hospital Charge Code |
APRDRG0072
|
| Min. Negotiated Rate |
$40,658.05 |
| Max. Negotiated Rate |
$40,658.05 |
| Rate for Payer: AHCCCS Medicaid |
$40,658.05
|
| Rate for Payer: Allwell Medicaid |
$40,658.05
|
| Rate for Payer: AZCH Complete Medicaid |
$40,658.05
|
| Rate for Payer: Banner UC Health Medicaid |
$40,658.05
|
| Rate for Payer: Mercy Care Medicaid |
$40,658.05
|
|
|
Allogeneic Bone Marrow Transplant
|
Facility
|
IP
|
$70,931.88
|
|
|
Service Code
|
APR-DRG 0073
|
| Hospital Charge Code |
APRDRG0073
|
| Min. Negotiated Rate |
$70,931.88 |
| Max. Negotiated Rate |
$70,931.88 |
| Rate for Payer: AHCCCS Medicaid |
$70,931.88
|
| Rate for Payer: Allwell Medicaid |
$70,931.88
|
| Rate for Payer: AZCH Complete Medicaid |
$70,931.88
|
| Rate for Payer: Banner UC Health Medicaid |
$70,931.88
|
| Rate for Payer: Mercy Care Medicaid |
$70,931.88
|
|
|
allopurinol 100 mg Tab [CQCH]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 51079020520
|
| Hospital Charge Code |
105909905
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Aetna of AZ Commercial |
$0.23
|
| Rate for Payer: Aetna of AZ Medicare |
$0.07
|
| Rate for Payer: Allwell Medicare |
$0.04
|
| Rate for Payer: Amerigroup Medicare |
$0.04
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.10
|
| Rate for Payer: AZCH Complete Medicare |
$0.04
|
| Rate for Payer: Banner UC Health Medicare |
$0.04
|
| Rate for Payer: Bisbee Police All Plans |
$0.07
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.18
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of AZ Commercial |
$0.17
|
| Rate for Payer: Copperpoint Commercial |
$0.06
|
| Rate for Payer: Health Net of AZ Commercial |
$0.16
|
| Rate for Payer: Health Net of AZ Medicare |
$0.07
|
| Rate for Payer: Humana of AZ Medicare |
$0.04
|
| Rate for Payer: Self Pay Self Pay |
$0.21
|
| Rate for Payer: TriWest Medicare |
$0.04
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.15
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.05
|
|
|
allopurinol 100 mg Tab [CQCH]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 51079020520
|
| Hospital Charge Code |
105909905
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Aetna of AZ Commercial |
$0.23
|
| Rate for Payer: Bisbee Police All Plans |
$0.07
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Self Pay Self Pay |
$0.21
|
|
